Human colon cells: culture and in vitro transformation.

Normal human colon mucosal epithelial cells were cultured in vitro and treated with the oncogenic simian DNA virus (SV40) and the chemical carcinogen azoxymethane. Both SV40 and azoxymethane altered a number of phenotypic characteristics of the normal human colon cells, including their morphology, culture longevity, growth in soft agar, substrate adherence, and peanut agglutinin binding. The SV40 transformants synthesized intranuclear T antigen. These data indicate that normal human colon mucosal cells were transformed toward the malignant phenotype.

Bleeding vascular malformations of the intestine.

Thirty-nine patients with bleeding vascular malformations were evaluated. The age range was from 3 to 78 years, with a bimodal age distribution. The younger patients had no associated diseases, while those in the older category invariably had an associated cardiac lesion (aortic stenosis in 12 patients and severe atherosclerotic disease in 11 patients). With experience, colonoscopy has become a valuable adjunct to arteriography with the lesion visualized in 12 patients. Arteriography is the most useful study being diagnostic in 35 of 38 cases. Exploration alone was diagnostic in only one of 39 patients. The most common site of bleeding was the cecum (21 patients) followed by the proximal small intestine (eight patients), terminal ileum (seven patients), and ascending colon (five patients). The lesions in the proximal small bowel were much more common in the younger patients and were believed to be congenital. Resection controlled the bleeding in the majority of patients, although four recurrences have been noted. All have been documented angiographically to have been from a new lesion and two were controlled with reoperation. The key elements to control of these patient's bleeding include: (1) systematic work-up with a team approach emphasizing careful visceral angiography, and (2) the avoidance of a premature laparotomy prior to complete evaluation.

Results of a prospective randomized study of hepatic artery infusion with 5-fluorouracil versus intravenous 5-fluorouracil in patients with hepatic metastases from colorectal cancer: A Central Oncology Group study.

In a controlled, prospectively randomized trial, 74 patients with hepatic metastases from colorectal cancer were randomized to either intra-arterial hepatic artery infusion with 5-fluorouracil (5-FU) or systemic chemotherapy with 5-FU. In 61 acceptable patients, there was no significant difference in terms of response rate, time to progression, duration of the response, and survival rate. Though the response rate for the intra-arterial infusion arm was slightly higher than for the systemic arm, the difference was not significant, and the intra-arterial infusion arm was associated with a greater incidence of nausea, vomiting, diarrhea, in addition to complications of femoral-arterial thrombosis, bleeding, and infection at the catheter site not seen in patients treated by systemic chemotherapy. Patients with an objective response to chemotherapy on either treatment arm survived twice as long as the nonresponders. Long-term survival in one patient, 77 months, can occasionally be achieved in patients with hepatic metastases.

Occult gastrointestinal bleeding. An evaluation of available diagnostic methods.

Occult gastrointestinal bleeding was defined as continued bleeding in spite of a normal series of roentgenorgrams of the upper part of the gastrointestinal tract, barium enema, and sigmoidoscopy. Twenty-six such patients were treated. A thorough systematic evaluation, including gastroscopy, colonoscopy, visceral angiography, and isotopic scanning, was done preoperatively. Using colonoscopy and arteriography, nearly 60% of the bleeding sites were identified. Seventy-six percent of the lesions identified were in the terminal part of the ileum or the ascending colon. Exploratory laparotomy should be performed for life-threatening hemorrhage or as a diagnostic test only after a thorough preoperative evaluation. If results of a complete preoperative evaluation including arteriography were normal, then the likelihood of finding a discrete cause of bleeding at laparotomy was high (80%). A systematic evaluation and diligence of both physcian and patient in localizing the site of bleeding are essential.

Hepatic trauma: pitfalls in management.

We reviewed 233 traumatic injuries to the liver. The mortality was 11%. Deaths were due to either uncontrolled intraoperative hemorrhage or the postoperative complications of multiple organ injuries. The majority of liver injuries can be safely managed with manual compression, porta hepatic control, simple sutures, or drainage. Liver injuries involving the hepatic veins or retrohepatic vena cava continue to be highly lethal despite the use of vascular isolation and hepatic resection.

Bowel obstruction and the long tube stent.

Fifty-eight cases of intestinal obstruction requiring operative intervention were reviewed. Enterolysis alone as the treatment for bowel obstruction as a result of adhesions appears to be as good or better than the long tube stent. Patients treated with enterolysis alone had a shorter period of postoperative ileus, a shorter hospital confinement following operation, and fewer recurrent obstructions. These patients also had a longer interval between episodes of reobstruction than did those treated with an intraluminal long tube stent.

Primary intrahepatic gallstones.

Caroli's disease is characterized by congenital segmental dilation of the intrahepatic bile ducts producing a variety of symptoms and, usually, primary intrahepatic gallstones. We are reporting five new cases of Caroli's disease in addition to the 91 reported in the literature. The diagnosis is made by intrahepatic cholangiography; techniques are emphasized. The diagnoses were confirmed by the surgical specimen of the left lobe of the liver in cases 1 and 2, by autopsy in case 3, and by intrahepatic cholangiogram in cases 4 and 5. The treatment resulted in leftsided lobectomy of liver in cases 1 and 2. Cholecystectomy, removal of common duct stones, choledochoduodenostomy or, preferably Roux-en-Y choledochojejunostomy, were done in cases 3, 4, and 5. Two patients died more than five years after their original surgery, and three are alive at six months, six, and 13 years, respectively. This is a more encouraging outcome than is usually reported.

Simple closure of perforated peptic ulcer. Still an effective procedure for patients with delay in treatment.

Sixty patients (mean age, 50 years) underwent simple closure of a perforated peptic ulcer. For 56 patients, average delay in treatment was 21.6 hours. Postoperatively, 21 patients (treatment delay, 30 hours) had either pulmonary or abdominal complications. Ten patients (treatment delay, 34 hours) died. Acute onset of ulcer symptoms prior to perforation was associated with a threefold increase in mortality compared with patients with chronic symptoms. Seven patients subsequently underwent vagotomy and partial gastrectomy without complications. This study demonstrates that in patients with peptic ulcer disease, perforation is an unusually frequent indication for operation; advanced age, treatment delay of 30 hours or more, and acute ulcer symptoms are associated with increased morbidity and mortality; and simple closure of the perforation remains an effective procedure in patients who have delayed seeking treatment.

Traumatic splenic injury: its management in a patient population with a high incidence of associated injury.

Nonoperative management of splenic trauma is receiving increasing support following delineation of the spleen's role in infection. Controversy regarding the proper management of this injury led us to study retrospectively 236 consecutive patients with splenic trauma. Blunt trauma occurred in the majority (161); the remainder suffered penetrating abdominal injury secondary to gunshot or stab wounds. Diagnostic peritoneal lavage was accurate in establishing splenic injury in blunt trauma (no false-positive, but three false-negative findings). Associated intra-abdominal injury occurred in 48% and 92% of patients with blunt and penetrating trauma, respectively. Diagnostic peritoneal lavage is an accurate method for establishing an intra-abdominal injury and the need for abdominal exploration in patients with blunt abdominal trauma. Because of the high rate of associated intra-abdominal injury in splenic trauma, nonoperative management can be expected to result in a disturbing incidence of missed intra-abdominal injury in patients with abnormal peritoneal lavage findings.

Biliary pancreatitis. Operative outcome with a selective approach.

To evaluate the efficacy of a selective approach to biliary pancreatitis, we reviewed the outcomes in 276 consecutive patients undergoing operations for this diagnosis during a 7-year period. Initial conservative therapy resulted in elective operations in 63% and urgent operations in 37%. Only 10 patients (3.6%) required primary pancreatic operations, 50% of them as emergencies. The proportion of common duct surgical explorations fell from 70% of those operated immediately after hospital admission to 20% by the third hospital day. Overall mortality was 1.8% but was increased to 30% in patients having an initial pancreatic operation. We conclude that a selective approach to biliary pancreatitis allows the operation to be performed electively in most patients and is associated with a low mortality and an acceptable length of stay. Most common duct stones pass spontaneously permitting cholecystectomy alone.

Effects of gastrin, glutamine, and somatostatin on the in vitro growth of normal and malignant human gastric mucosal cells.

This study evaluated the dose-related trophic effects of glutamine, gastrin, and somatostatin on the in vitro growth of human gastric cancer cells and normal human gastric mucosal cells. Quadruplicate cell cultures were seeded into growth medium with or without glutamine, gastrin, or somatostatin. After 72 hours' incubation, cells were counted and their numbers compared with those of controls. Glutamine and gastrin stimulated the growth of both normal and malignant gastric mucosal cells. Compared with normal cells, the malignant cells responded to these growth factors at lower concentrations. Somatostatin enhanced growth of gastric cancer cells at all concentrations and inhibited growth of normal cells at high concentrations. Further studies on the responsiveness of gastric adenocarcinoma to gastrointestinal tract hormones may elucidate mechanisms of oncogenesis and suggest new therapeutic avenues for patients with gastric cancer.

Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study.

BACKGROUND: The National Veterans Affairs Surgical Risk Study was designed to collect reliable, valid data on patient risk and outcomes for major surgery in the Veterans Health Administration and to report comparative risk-adjusted postoperative mortality rates for surgical services in Veterans Health Administration. STUDY DESIGN: This cohort study was conducted in 44 Veterans Affairs Medical Centers. Included were 87,078 major noncardiac operations performed under general, spinal, or epidural anesthesia between October 1, 1991, and December 31, 1993. The main outcomes measure was all-cause mortality within 30 days after the index procedure. Multivariable logistic regression risk-adjustment models for all operations and for eight surgical subspecialties were developed. Risk-adjusted surgical mortality rates were expressed as observed-to-expected ratios and were compared with unadjusted 30-day postoperative mortality rates. RESULTS: Patient risk factors predictive of postoperative mortality included serum albumin level, American Society of Anesthesia class, emergency operation, and 31 additional preoperative variables. Considerable variability in unadjusted mortality rates for all operations was observed across the 44 hospitals (1.2-5.4%). After risk adjustment, observed-to-expected ratios ranged from 0.49 to 1.53. Rank order correlation of the hospitals by unadjusted and risk-adjusted mortality rates for all operations was 0.64. Ninety-three percent of the hospitals changed rank after risk adjustment, 50% by more than 5 and 25% by more than 10. CONCLUSIONS: The Department of Veterans Affairs has successfully implemented a system for the prospective collection and comparative reporting of risk-adjusted postoperative mortality rates after major noncardiac operations. Risk adjustment had an appreciable impact on the rank ordering of the hospitals and provided a means for monitoring and potentially improving the quality of surgical care.

Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study.

BACKGROUND: The National Veterans Affairs Surgical Risk Study was designed to collect reliable, valid data on patient risk and outcomes for major surgery in the Veterans Health Administration and to report comparative risk-adjusted postoperative mortality and morbidity rates for surgical services in the Veterans Health Administration. STUDY DESIGN: This was a cohort study conducted at 44 Veterans Affairs Medical Centers closely affiliated with university medical centers. Included were 87,078 major noncardiac operations performed under general, spinal, or epidural anesthesia between October 1, 1991, and December 31, 1993. The main outcomes measures in this report are 21 postoperative adverse events (morbidities) occurring within 30 days after the index procedure. Multivariable logistic regression risk-adjustment models for all operations and for eight surgical subspecialties were developed. RESULTS: Patient risk factors predictive of postoperative morbidity included serum albumin level, American Society of Anesthesia class, the complexity of the operation, and 17 other preoperative risk variables. Wide variation in the unadjusted rates of one or more postoperative morbidities for all operations was observed across the 44 hospitals (7.4-28.4%). Risk-adjusted observed-to-expected ratios ranged from 0.49 to 1.46. The Spearman rank order correlation between the ranking of the hospitals based on unadjusted morbidity rates and risk-adjusted observed-to-expected ratios for all operations was 0.87. There was little or no correlation between the rank order of the hospitals by risk-adjusted morbidity and risk-adjusted mortality. CONCLUSIONS: The Department of Veterans Affairs has successfully implemented a system for the prospective collection and comparative reporting of postoperative mortality and morbidity rates after major noncardiac operations. Risk adjustment had only a modest effect on the rank order of the hospitals.

Isolated cystic dilatation of the cystic duct.

Presented was an unusual case of congenital cystic dilatation of the extrahepatic biliary tract in which the cystic changes were confined solely to the cystic duct. There was concomitant common bile duct obstruction secondary to inflammation and mass effect from the cyst. Management consisted of cholecystectomy, excision of the cyst, common bile duct exploration, examination of the ampullary region by duodenotomy, and choledochoduodenostomy.

The management of carcinoma of the larynx in a prominent patient, or did Morell Mackenzie really cause World War I?.

The influence of fate on history is a fascinating subject. This paper reviews the death of the Crown Prince of Prussia from carcinoma of the larynx. This was a critical turning point in history. The roles of the European physicians involved in his care are reviewed. It was not until after the death of Queen Victoria that the true character of these physicians was revealed.

Penetrating injuries to the neck. Pitfalls in management.

One hundred patients with penetrating injuries to the neck were evaluated. The safest, most expeditious method of managing a penetrating injury to the neck is still prompt surgical exploration. Patients with positive physical examination have definite indications for surgerymin our series, 93 per cent of these patients had significant injuries. Patients with negative physical examinations are still optimally treated with neck explorations. The mortality of this series was 2 per cent. In specific situations, nonoperative management of penetrating injuries to the neck may be useful. This modality, however; should not be construed as "conservative" management. Specific pitfalls noted include inadequate neck exploration, failure to completely examine the patient, and being unprepared for exploration outside the neck.

Orchiectomy during herniorrhaphy: what should we tell the patient?

Although orchiectomy is rarely required during inguinal herniorrhaphy, it is frequently a topic of preoperative concern. Our study disclosed a concomitant orchiectomy rate of 2 percent during 1,817 groin herniorrhaphies. The risk of orchiectomy was greatest in patients with incarceration (relative risk 22 times) but was also increased by herniorrhaphy for recurrence (relative risk 8 times) (Table II). On the other hand, patients undergoing repair of a primary reducible hernia were at low risk. Of the 29 patients undergoing orchiectomy, only 12 of the procedures were performed for specifically recorded testicular or spermatic cord abnormalities. The precise reason for orchiectomy was often not stated or was vague. We conclude that orchiectomy is more likely to be associated with repair of complicated hernias and that permission for possible orchiectomy should be obtained from these patients preoperatively. On the other hand, consent for orchiectomy and detailed discussion is unwarranted for patients with primary reducible hernias. In addition, orchiectomy during herniorrhaphy should be limited to cases of specific testicular and cord abnormalities, and the reason for orchiectomy should be clearly documented in the operative record.

Antivenin and fasciotomy/debridement in the treatment of the severe rattlesnake bite.

This experimental study of severe rattlesnake envenomation compares antivenin alone, fasciotomy and debridement alone, and a combination of the two methods as definitive treatment. Superior survival and preservation of muscle function were observed in the animals treated with antivenin alone.

Operative management of thyroid disease. Technical considerations in a residency training program.

Experience with 294 thyroid operations at Medical Center Hospital as performed by resident housestaff in general surgery has been reported. Operative results were consistent with the morbidity and mortality figures from large reviews. The importance of an active role for surgical housestaff in the operative management of thyroid disease is emphasized. With close supervision and attention to intraoperative identification of the recurrent laryngeal nerves and parathyroid glands, satisfactory results can be achieved.

Glucagon enhances growth of cultured human colorectal cancer cells in vitro.

Early passage in vitro cultures of colorectal adenocarcinoma cells were used to determine if glucagon exerts a direct effect on growth of human colon cancer cells. Growth response assays indicated that glucagon generally stimulated growth between 2 and 10 micrograms/ml, with peak responses at 5 to 10 micrograms/ml. When glucagon-treated and control cultures were compared, 12 of the 14 cultures (86 percent) were stimulated by glucagon, with an increase in cells from 41 to 100 percent. The other two cultures did not respond to glucagon. These in vitro results suggest that glucagon may enhance growth of most colon cancer cells. Further studies on responsiveness to glucagon may help elucidate mechanisms of oncogenesis and suggest new therapeutic protocols for patients with colorectal cancer.